CLINICAL ARTICLES

Instrumentation of root canals in molar using

the step-down technique

Ltc Albert C. Goerig, DDS, MS; Robert J. Michelich, DDS; and Cpt Howard H. Schultz, DMD

A t e c h n i q u e for p r e p a r a t i o n of m o l a r root canals is described. After

access to t h e canal orifices is o b t a i n e d , t h e c o r o n a l p o r t i o n of the
canal is e n l a r g e d w i t h a s t e p - d o w n t e c h n i q u e , a n d t h e apical
p r e p a r a t i o n is c o m p l e t e d w i t h a step-back t e c h n i q u e .

The endodontic management of molar
root canals can be difficult and frus-
trating. In an attempt to improve
treatment resuhs, a number of arti-
cles '9 have been written to present a
practical and scientific approach for
instrumenting these canals. The
authors have described methods for
effective debridement and shaping of
the canal system while minimizing the
occurrence of procedural accidents.
The step-back or telescopic filing
produces a flared canal shape that
facilitates the placement of gutta-per-
cha. 26 This article describes a step-
down technique of radicular access
and a modified step-back technique of
apical preparation.
Endodontic preparation of any tooth
and the development of a straight line instrument to enter the canal without
path through the crown to the canal interference, thus reducing the overall
orifices (Fig 2). Before beginning degree of instrument bend.
access preparation, the tooth should be
examined clinically and radiographi- RADICULAR ACCESS
cally for rotations and axial inclina-
tions. The radiographs should also be Radicular access is made by opening
inspected to determine the shape and and flaring the coronal half to two-
size of the chamber, and the direction,
shape, and size of the canals. The roof
of a molar pulp chamber is approxi-
mately at the level of the cemento- COROI
enamel junction, and the pulp horns ACCE5
may extend to the proximal height of
contour (Fig 3). These anatomic and
radiographic landmarks are used as
guides to depth in locating the cham- RADIC
ACCES
ber. The effects of caries, large restora- STEP ~/
tions, and age can cause a reduction in DOWN~

can be separated into three processes:
coronal access, radicular access (step-
down technique), and apical instru-
mentation (step-back technique) (Fig
1). Coronal and radicular access are
established to obtain direct line access
to the apical third of the canal.
CORONAL ACCESS
Coronal access is made with the
initial opening into the pulp chamber
the size of the chamber and should be
taken into consideration when these
landmarks are interpreted. A no. 4
round bur is recommended for pene-
trating the chamber and lifting off the
roof. If the chamber has a short occlu-
sal-gingival height, a brushing motion
is used to uncover the chamber. Dentin
ledges that extend from the proximal
chamber wall and obscure the canal
orifices should be removed with the
round bur. This reduction allows the
/
\
STEP~
BACK~I
, APICAL
I INSTRUI
Fig 7- Endodontic instrumentation is
separated 'nto coronal access, radicular
access (step-down technique), and apical
instrumentation (step-back technique).
Dentin is removed during coronal and ra-
dicular access (dotted lines) to provide
straight line path to apical third of canal.

550

b)g 2---Coronal access. No. 4 round bur
has been used to fienetrate chamber, hft
off roo/ of chamber, and remove dentin
ledges overlying orifices.
thirds of the canal to eliminate dentin-
al irregularities and pulpal tissue (Fig
t)?'s'~~ This can be accomplished rap-
idly and effectively with Hedstroem
files and Gates-Glidden burs. The
step-down technique of radicular
access is accomplished before instru-
mentation of the apical third of the
canal is completed and provides cer-
tain advantages:
- - I t permits straighter access to the
apical region;
--l,t eliminates dentinal interfer-
ences found in the coronal two-thirds
of the canal, allowing apical instru-
mentation to be accomplished quickly
and efficiently;
- - T h e bulk of the pulp tissue,
debris, and microorganisms are
removed before apical instrumenta-
J O U R N A L OF E N D O D O N T I C S I V O L 8, N O 12, DECEMBER 1982
Fig 3 - - R o o f af molar pulp chambers zs
approxzmately at level of cementoenamel
junction, serving as depth guide during
coronal access.
tion, greatly reducing the number of
contaminants that could be extruded
during apical instrumentation and
could cause periapical inflammation.
- - T h e enlargement during radicu-
lar access allows a deeper penetration
of irrigating solutions.
- - T h e working length is less likely
to change during subsequent apical
instrumentation because the canal cur-
vature has been reduced before estab-
lishing the working length. 2,~
The pulp chamber is first copiously
irrigated, followed by sequential intro-
duction of Hedstroem file sizes 15, 20,
and 25 into the canals (Fig 4). These
files are introduced to a depth of 16 to
18 mm, or where the files start to bind
against the canal walls. This depth
approximates the junction of the mid-
dle and apical thirds of the root. If the
preoperative radiograph shows a
molar with short roots, the depth to
which the instruments are placed is
decreased. In small or calcified canals,
the canal is first instrumented into the
apical portion with nos. 8 and 10
K-files, facilitating the placement of
the Hedstroem files and establishing
patency of the canal. The Hedstroem
files are placed by using light apical
pressure; they should never he screwed
or forced apically. They are used in a
rapid up and down motion with the
file rasping the canal wall during its
# 3 GATES ; '/,~_\,,,,,
GLIDDEN BUR ;, /
#2 GAIES 'i ; ~1
GLIDDEN BUR;:
#15-25 HEDSTROMII: \' \,' ~!
t,'~g7 4--Radicular access. Coronal two-
thirds of canal is enlarged u,,i/h tIed-
stroem files and Gates-Glidden burs. In-
struments are used zz,ith hght apical pres-
sure and lateral pressure directed away
.[ram furcatum, which results i1~ strmghter
access to apical third.
outward movement. The filing is
directed against the canal wall farthest
from the furcation (Fig 5). After using
the no. 15 I tedstroem file, nos. 20 and
25 files are inserted into the canal
decreasing the length for each by
approximately 0.5 mm and worked
with the same rasping motion. In a
small canal, a no. 10 K-file is used to
renegotiate into the apical third. I,edg-
ing and blockage of the canal can be
avoided by decreasing the lengths and
recapitulation. This filing sequence
quickly eliminates dentinal interfer-
ences and pulpal tissue. It also
enlarges the canal sufficiently for the
unhindered placement of the Gates-
Glidden burs.
After the Hedstroem files are used,
the canal is irrigated. Gates-Glidden
burs are introduced into the canal,
beginning with a no. 2 bur and fol-
lowed with a no. 3. Tile no. 2 bur is
placed 14 to 16 mm from the occlusal
reference into the canal with light
apical pressure. The no. 3 bur extends
11 to 13 mm into the canal and is
551

Fig 5--Hedstroem files (size 27 ram) are
used in radicular access to remove denti-
nal interferences and enlarge canal. Files
are directed against canal wall farthest
from furcation to provide direct line to
apical portion of canal.
directed apically and laterally away
from the furcation. The no. 3 bur
funnels the canal 2 to 4 mm apical to
the canal orifice (Fig 4). A no. 4
Gates-Glidden bur can also be used in
larger canals. These burs should be
rotated with a constant medium drill
speed from the time they enter the
canal until they are removed. They are
placed with light pressure and must
never be forced apically or laterally.
The initial canal preparation with
files is necessary to reduce the risk of
bur breakage. If they do break, the
shaft usually separates near the hand-
piece head and is readily retrieved
from the tooth. Repeated use and ster-
ilization of these burs make them
more susceptible to fracture. Before
introducing one into the canal, test the
552
JOURNAL OF ENDODONTICS [ VOL 8, NO 12, DECEMBER 1982
Fig 6--Left, stripping and per-
foration of furcal portion of root;
Right, clinical view of area of
perforation (arrows).
integrity of the bur by flicking it with a
cotton plier.
This use of Hedstroem files and the
Gates-Glidden burs creates a flared
preparation in the coronal half to two-
thirds of the canal, resulting in a
straighter access to the apical portion
of the canal. However, overflaring
must be avoided because it weakens
)
sS
the tooth and may result in a perfora-
tion (Fig 6). Stripping perforations on
the furcal side of the root canal can be
prevented by limiting the circumferen- FURCA
tial filing to the areas of greatest bulk?
These areas generally lie on the buc-
cal, lingual, and proximal surfaces of
the root opposite the furcation (Fig 7).
For example, when preparing the \
mesiobuccal canal of a mandibular
I
molar, the Hedstroem files and Gates-
Glidden burs should be directed away
from the furcation and toward the
mesiobuccal line angle of the tooth.
Removal of dentin in this area pre-
vents a perforation and gives straighter L
access to the apical third of the Fig 7~Areas of greatest bulk lie toward
canal. buccaI (B)', lingual (L), and proximal
Instrumentation with the step-dow n (P). Enlargement in coronal third is di-
technique of radicular access is accom- rected toward these areas (dotted lines).
plished using only light pressure
directed apically and toward areas of
greater dentin bulk. It is done with
decreasing lengths as the instrument
diameter is increased. Once the coro-
nal and radicular access is obtained,
the apical third of the canal is pre-
pared.
APICAL
INSTRUMENTATION
The canal length must be deter-
mined before the step-back filing is
started. A knowledge of apical root
anatomy is helpful in determining the
length of the canal and the apical
extent of instrumentation. T h e radio-
graphic apex is the anatomic end of the
root as seen on X-ray film, whereas
the apical foramen is the position on
the root end where the canal exits. T h e
canal narrows and then diverges api-
cally (Fig 8). T h e canal length is the
distance from a reference point on the
crown to the apical foramen. In 50% to
98% of root apexes, the apical foramen
does not coincide with the anatomic
apex. 12-~6It usually exits approximate-
ly 0.5 m m from the apex and may exit
2 m m or 3 m m from the apex. 14'~5Von
der Lehr and Marsh ~6 found that the
position of the apical foramen can
most accurately be determined when
the file extends to the external root
surface on the radiograph.
An estimation of the canal length
can be obtained by placing the initial
file against the diagnostic radiograph
exposed with a paralleling technique
and adjusting the rubber stop to the
length, of the tooth. T h e measurement
file is bent slightly in the apical ] to 2
m m to help bypass any canal irregu-
larities. It is then placed into the canal
using a reciprocal rotating motion
between the thumb and index finger
and advanced to the apical foramen
using light apical pressure (Fig 9). A
AO
CPC
INS
A
~TLR ~
/
APC
I AFO
LRAMEN
RAD;OG~AF'.,C APEX
Fig 8--Apical foramen of canal is not lo-
cated at radiographic apex in most teeth.
Canal narrows to apical constriction be-
fore diverging apically.
no. 10 K-file is the initial instrument
used in small canals. However, the
canal should be enlarged to allow
placement of a no. 15 K-file because it
is more easily seen on the length
determination film.
Measurement radiographs exposed
with a 20 to 30 degree horizontal
deviation are used to separate super-
imposed files and determine the loca-
tion of the foramen. Increasing the
exposure time by one to two settings
will accentuate the more radiopaque
structures, improving the visibility of
root apexes and instruments in the
canal on the measurement film_ If the
file is not within 1 m m of the foramen,
then it should be repositioned in the
canal and a second film exposed_ Addi-
tional films may be necessary to give
the operator a more accurate image of
the canal curvature, number of canals,
and exit point of the file.
There are differing opinions on the
optimum apical extent of canal instru-
mentation and filling materials. 2,4,6,~4
Kuttler TM found the apical constriction
to be an average of 0.52 mm to 0.66
m m from the apical foramen and sug-
gested that it was an ideal point to
terminate the filling material. An api-
cal seat prepared at this level acts as a
matrix and resists displacement of the
filling material through the apical
foramen. T h e location of the apical
constriction varies with age, TM and the
Fzg 9--Curvatures and interferences in
coronal two-thirds of canal have been
eliminated. When file is advanced to api-
cal foramen, canal length is measured
from tip o/file to rubber stop.
presence of apical resorption. 6 Because
it is difficult to determine clinically
where the apical constriction lies,
instrumenting with small files to the
apical foramen is recommended 4 to
ensure apical debridement.
The apical portion is debrided with
a no. 15 or no. 20 K-file to the apical
foramen (Fig 10). An apical seat is
established with a no. 25 file, 0.5 to 1.0
mm short of the apical foramen. T h e
apical seat is prepared farther from
the apical foramen when marked root
resorption is present. 6 Initially, a
curved canal is not instrumented to the
apical seat larger than a no. 25 to no.
30 size file. T h e use of larger instru-
ments to the apical seat may lead to
ledging or zipping perforation 7'9 of the
canal. T h e apical third of the canal
(curved portion) is then instrumented
using the step-back technique. This
preparation is accomplished by
decreasing the length of successively
larger files by 0.5-1.0 m m (Fig 10).
T h e technique has been described by
various authors 16 and is effective in
removing debris and dentin. ~,s
553
 30 19.0 ml
?5' 20 19.Ore
60 15.5 --")
5 5 16.0 /
50 16.5 [
4 5 17.0
4o175 8
35 18.0
30 18.5 \
25 19mm .J
:----15 20ram
~ 1 0 20ram
Fig lO--Apical instrumentation. A, canal
is debrided to apical foramen with small
files; B, apical seat is established 1.0 mm
short of apical foramen. Sequentially
larger files are used at decreasing lengths
of 0.5 mm in step-back preparation. Fre-
quent recapitulation with small file to
apical seat will prevent blockage of canal
and smooth canal walls. C, apical seat is
defined with no. 20 to no. 30 files placed
to apical seat.
T h e K-files are used in a r e a m i n g
action. Schilder 4 defines this as a 180
degree rotation and w i t h d r a w a l of the
i n s t r u m e n t as it contacts the canal
walls. T h e i n s t r u m e n t is placed into
the canal with apical pressure u n t i l it
binds, rolled between the t h u m b and
forefinger for 90 to 180 degrees, with-
d r a w n several millimeters against the
canal wall, and then reinserted. T h i s
r e a m i n g action can be repeated quick-
ly u n t i l the file fits loosely in the canal
at the proper length. S e q u e n t i a l files
are used with this r e a m i n g action
while "stepping back" with the
lengths. U s i n g the next larger i n s t r u -
m e n t too fast can lead to blockage and
loss of i n s t r u m e n t length. I n s t r u m e n t s
should never be forced d o w n the canal.
If there is difficulty in reaching the
apex, a smaller i n s t r u m e n t should be
used. T h i s recapitulation technique
p e r m i t s smoothing a n d flaring of the
canal p r e p a r a t i o n while preventing
blockage of the canal with dentinal
mud. A no. 25 K-file is used to recapit-
ulate to the apical seat d u r i n g step-
back filing.
I n s t r u m e n t a t i o n is done in a well-
irrigated field. Copious a m o u n t s of
s o d i u m hypochlorite solution should
be used to lubricate the canal system
and suspend dentinal debris.
After the canals are dried, a n y den-
tinal debris r e m a i n i n g in the apical
portion of the canal is removed with
554
A Fig 11--Root canals in this mandibular
molar were prepared using step-down
technique. Canals have continuously ta-
pering.form and have been obturated
with gutta-percha to apical seal.
the no. 25 K-file. T h e apical seat is
further defined with a no. 30 K-file or
no. 35 K-file. E n l a r g e m e n t of the
apical seat facilitates the placement of
the m a s t e r cone (Fig 10). These larger
files can be used after the apical canal
curvature has been reduced with the
step-back technique. T h e completed
root canal p r e p a r a t i o n has a c o n t i n u -
ous conical form that tapers to the
apical seat,
A n e x a m p l e of a molar obturated
after canal p r e p a r a t i o n using the step-
down t e c h n i q u e is shown in F i g u r e
11.
SUMMARY
I n s t r u m e n t a t i o n of root canals in
molars using the step-down t e c h n i q u e
of r a d i c u l a r access with a modified
step-back technique apical p r e p a r a -
tion has been described. T h i s tech-
n i q u e simplifies apical i n s t r u m e n t a -
tion because immediate direct-line
access to the apical third of the tooth is
used, which increases the operator's
speed a n d the predictability of the final
endodontic fill.
The opinions or assertions contained herein
are the private views of the authors and are not
to be construed as official or as reflecting the
views of the Department of the Army or the
Department of Defense.
The authors thank Ms. Connie Reed, Ms.
Linda Glass, and Ms. Janice Burnell for their
assistance in the preparation of this manuscript,
and M[s. Carita Powell for her contribution and
expertise as a medical illustrator.
Dr. Goerig is Commander and Chief of
Endodontic 124th MED. DET. (DS), APO
NY, 09189, Dr. Michelich is associate professor
of endodontics, Emory University School of
Dentistry, Atlanta. Dr. Schuhz is a staff dentist,
Nelson Dental Clinic, Fort Knox, Ky. Requests
for reprints should be directed to Dr. Goerig.
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